Predictive power of a single body temperature at different cutoff values for neonates in the nursery transferring to special care nursery

The aim of this study was to identify the clinical parameters indicative of serious etiology of neonatal hyperthermia and to determine the appropriate cutoff value of body temperature (BT) for predicting the need to transfer the newborn to the special care (SC) nursery.The nursery records of newborns diagnosed with hyperthermia between 2007 and 2013 were retrospectively reviewed. The clinical characteristics of newborns with hyperthermia remained in the nursery were compared with those transferred to the SC nursery. In addition, the receiver operating characteristic analysis was used to determine the appropriate cutoff BT for predicting further septic workup in the SC nursery.Among the 92 newborns with hyperthermia evaluated, 30 (32.6%) were transferred to the SC nursery and 62 (67.4%) remained in the nursery. Clinical characteristics associated with transfer to the SC nursery included the highest BT, BT at first measurement during hyperthermia, frequency of hyperthermia, duration of hyperthermia, irritable crying, decreased appetite, poor activity, vomiting with abdominal distension, tachypnea, and tachycardia (all P < .05). BT for predicting the need for transferring newborns with hyperthermia to the SC nursery had an area under the curve of 0.976 (P < .001). A BT of 38 °C was determined as the optimal cutoff value for predicting the need to monitoring for suspicious clinical symptoms (sensitivity (Sn), 93%; specificity (Sp), 87%). Furthermore, BT≥38.2 °C (Sn, 70%; Sp 100%) and BT≤37.8 °C (Sn, 100%; Sp, 61%) respectively were determined as the cutoff values for transferring newborns to the SC nursery or allowing them to remain in the regular nursery.Our results suggest a BT of 38 °C represents the optimal cutoff indicating newborns for close monitoring for suspicious clinical presentations including irritable crying, decreased appetite, poor activity, vomiting with abdominal distension, tachypnea, and tachycardia. Newborns with BT < 37.8 °C may remain in the nursery but should be transferred to the SC nursery for septic workup and empiric antibiotics if the BT is above 38.2 °C.

Indoor airborne fungal pollution in newborn units in Turkey

Pathogenic and/or opportunistic fungal species are major causes of nosocomial infections, especially in controlled environments where immunocompromised patients are hospitalized. Indoor fungal contamination in hospital air is associated with a wide range of adverse health effects. Regular determination of fungal spore counts in controlled hospital environments may help reduce the risk of fungal infections. Because infants have inchoate immune systems, they are given immunocompromised patient status. The aim of the present study was to evaluate culturable airborne fungi in the air of hospital newborn units in the Thrace, Marmara, Aegean, and Central Anatolia regions of Turkey. A total of 108 air samples were collected seasonally from newborn units in July 2012, October 2012, January 2013, and April 2013 by using an air sampler and dichloran 18% glycerol agar (DG18) as isolation media. We obtained 2593 fungal colonies comprising 370 fungal isolates representing 109 species of 28 genera, which were identified through multi-loci gene sequencing. Penicillium, Aspergillus, Cladosporium, Talaromyces, and Alternaria were the most abundant genera identified (35.14, 25.40, 17.57, 2.70, and 6.22% of the total, respectively).

Handwashing Practices in Neonatal Intensive Care Unit, Paediatric Intensive Care Unit and Neonatal Nurseries in Patan Hospital

BACKGROUND

Hand hygiene has been identified as the single most important factor in minimising hospital acquired infections. However, compliance of handwashing guidelines has remained low. The aim of this study was to study the handwashing practices in the Paediatric and Neonatal intensive care units and Neonatal nurseries in Patan Hospital, and secondly to re-evaluate the improvement on compliance of handwashing guidelines after intervention.

METHODS

Pre-intervention study was conducted by covertly observing the handwashing practices by the healthcare workers. The healthcare workers were then shown the video demonstrating correct methods of handwashing as recommended by World health organization. The cycle was completed by discretely re-observing the handwashing practices following intervention.

RESULTS

Sixty five samples were collected initially. Only 6 (9.2%) had completed all steps of handwashing correctly. Post- intervention, 51 samples were collected, out of which 35 (68.6%) had correctly completed all the steps. Following audio-visual demonstration, 100% correctly completed 8/10 steps of handwashing with soap and water. 8 (16%) failed to dry hands using a single use towel and 14 (28%) failed to turn off the tap using elbow. Post- intervention, 100% correctly completed 4/7 steps of handwashing using chlorhexidine. Four (15%) still failed to rub backs of fingers to opposite palm, eight (30%) failed to palm to palm with fingers interlaced, and rub thumb to opposite palm.

CONCLUSIONS

Compliance in hand hygiene is low despite the known fact that it reduces nosocomial infections. However, a simple intervention like video demonstration can improve the compliance among healthcare workers.

The Prolonged Neonatal Admission: Implications for our National Children's Hospital

A significant number of neonates are admitted to tertiary paediatric units for prolonged stays annually, despite limited availability of neonatal beds. As the three Dublin paediatric hospitals merge, this pressure will be transferred to our new National Children's Hospital. We analysed epidemiological trends in prolonged neonatal admissions to the 14-bed neonatal unit in The Children's University Hospital, Temple Street, Dublin. This was with a view to extrapolating this data toward the development of a neonatal unit in the National Children's Hospital that could accommodate for this complex, important, and resource-heavy patient population. Four hundred and thirty-six babies between 0 and 28 days of life were admitted to our neonatal unit for prolonged stays (three cohorts: >1 month and <3months, >3months and <6months, and >6months), between 2000-2014. Mean number of prolonged admissions >1 month was 29.1 per year (range 18-43). Median length of stay (LOS) was 42 days (range 29-727). 363 babies were admitted for >1month but <3months with a median LOS 38 days (range 28-90); 54 babies were admitted for >3months but <6months with a median LOS 111 days (range 91-179); 19 babies were admitted for >6months with a median LOS 331 (range 196-727). There has been a statistically significant upward trend in the number of prolonged admissions over last fifteen years (Spearman's rho p=0.01, correlation coefficient 0.848). There has been no significant increase in the median length of stay over time. It can be extrapolated, that in the new children's hospital must be capable of dealing with at least 80 neonatal long-stay patients annually.

Cross-sectional survey of California childbirth hospitals: implications for defining maternal levels of risk-appropriate care

OBJECTIVE

Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care.

STUDY DESIGN

We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care).

RESULTS

The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level.

CONCLUSION

Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care.

Use of health services by remote dwelling Aboriginal infants in tropical northern Australia: a retrospective cohort study

BACKGROUND

Australia is a wealthy developed country. However, there are significant disparities in health outcomes for Aboriginal infants compared with other Australian infants. Health outcomes tend to be worse for those living in remote areas. Little is known about the health service utilisation patterns of remote dwelling Aboriginal infants. This study describes health service utilisation patterns at the primary and referral level by remote dwelling Aboriginal infants from northern Australia.

RESULTS

Data on 413 infants were analysed. Following birth, one third of infants were admitted to the regional hospital neonatal nursery, primarily for preterm birth. Once home, most (98%) health service utilisation occurred at the remote primary health centre, infants presented to the centre about once a fortnight (mean 28 presentations per year, 95%CI 26.4-30.0). Half of the presentations were for new problems, most commonly for respiratory, skin and gastrointestinal symptoms. Remaining presentations were for reviews or routine health service provision. By one year of age 59% of infants were admitted to hospital at least once, the rate of hospitalisation per infant year was 1.1 (95%CI 0.9-1.2).

CONCLUSIONS

The hospitalisation rate is high and admissions commence early in life, visits to the remote primary health centre are frequent. Half of all presentations are for new problems. These findings have important implications for health service planning and delivery to remote dwelling Aboriginal families.

A reduction of necrotising enterocolitis at Groote Schuur Hospital nursery

Necrotising enterocolitis (NEC) is an gastro-intestinal emergency occurring almost solely in preterm, low birth weight infants. Mortality, morbidity and the complication rate are high. An increase in NEC at the Groote Schuur Hospital nursery in 2008 prompted a change of practice, resulting in a significant decrease in the condition.

A survey of infection control practices in the delivery room and nursery to investigate and control the high rate of neonatal sepsis: an experience at a secondary care hospital

OBJECTIVE

To survey the infection control practices in the delivery room and the nursery so that the ongoing high rate of neonatal sepsis can be controlled.

METHOD

A prospective study was conducted at the Department of Pathology, Paediatrics and Gynae/obst Combined Military Hospital, Gujranwala. Situation analysis was carried out, according to which a total of 56 cases of neonatal sepsis were diagnosed on the basis of clinical and lab criteria during a six month period from November 2005 to April 2006. The routine being followed in relation to neonates was observed by a team of doctors in the delivery room and the nursery. Certain observations were made regarding breach of infection control practices and specimens were collected from suspected sources of infections for cultures. Recommendations were made in the light of observations and the results of cultures of the specimens to interrupt the chain of infection and to eradicate the source/reservoir of infections in the delivery room and the nursery environment. The gynaecologist and the paediatrician in charge of the delivery room and the nursery respectively remained involved during the whole process and the paramedical staff was given necessary training in the light of recommendations.

RESULTS

After the implementation of the control measures, the rate of neonatal sepsis was drastically reduced from 63/1000 to 14/1000 live births over the next 3 months.

CONCLUSION

Survey of the delivery room and nursery regarding infection control practices and training of the paramedical staff helped in reducing the nosocomial neonatal sepsis.

Effects of antenatal depression and antidepressant treatment on gestational age at birth and risk of preterm birth

OBJECTIVE

The authors evaluated the effects of prenatal antidepressant exposure and maternal depression on infant gestational age at birth and risk of preterm birth.

METHOD

Ninety women were followed in a prospective, naturalistic design through pregnancy with monthly assessments of symptoms of depression and anxiety using the Structured Clinical Interview for DSM-IV mood module for depression, the Hamilton Depression Rating Scale, the Beck Depression Inventory, and the Perceived Stress Scale. Participants included 49 women with major depressive disorder who were treated with antidepressants during pregnancy (group 1), 22 women with major depressive disorder who were either not treated with antidepressants or had limited exposure to them during pregnancy (group 2), and 19 healthy comparison subjects (group 3). The primary outcome variables were the infants' gestational age at birth, birth weight, 1- and 5-minute Apgar scores, and admission to the special care nursery.

RESULTS

Groups 1, 2, and 3 differed significantly in gestational age at birth (38.5 weeks, 39.4 weeks, 39.7 weeks, respectively), rates of preterm birth (14.3%, 0%, 5.3%, respectively), and rates of admission to the special care nursery (21%, 9%, 0%, respectively). Birth weight and Apgar scores did not differ significantly between groups. Mild to moderate depression during pregnancy did not affect outcome measures.

CONCLUSIONS

Prenatal antidepressant use was associated with lower gestational age at birth and an increased risk of preterm birth. Presence of depressive symptoms was not associated with this risk. These results suggest that medication status, rather than depression, is a predictor of gestational age at birth.

Supine Sleeping Position Does Not Cause Clinical Aspiration in Neonates in Hospital Newborn Nurseries

OBJECTIVES

To determine the frequency and severity of clinically significant events of spitting up in normal newborns during the first 24 hours of life and to correlate the events with sleeping position.

DESIGN

Prospective observational study.

SETTING

Children born between August 2003 and October 2004 in newborn nurseries at 2 hospitals.

PARTICIPANTS

Healthy full-term newborns (n=3240) (>or=37 weeks estimated gestational age) during the first 24 hours of life.

OUTCOME MEASURES

Frequency of, and intervention required for, spitting up in supine, side-lying, and prone positions while asleep and awake.

RESULTS

Of the 3240 infants, 96.6% did not spit up during sleep. A total of 142 episodes of spitting up were documented in 111 newborns during sleep. While the newborns were supine and asleep, there were 130 episodes of spitting up. Of these episodes, 55% did not require any intervention, 37% only required brief suctioning with a bulb syringe, 6% required gentle stimulation, and 2% required wall suction. Both nurseries had a policy that newborns should sleep supine; therefore, only 6 newborns were noted to have spitting up episodes while lying on the side, with 66.7% requiring no intervention and 33.3% requiring bulb syringe. No episodes of apnea, cyanosis, documented aspirations, neonatal intensive care unit admissions, or deaths from spitting up were noted.

CONCLUSIONS

We conclude that clinically significant spitting up occurs infrequently in hospital newborn nurseries while the newborns are asleep. Fewer than 4% of newborns spit up while sleeping in the supine position in the first 24 hours of life, and none required significant intervention or experienced serious sequelae.

[Hospital practice in neonatal period to prevent infant sudden death syndrome]

OBJECTIVE

To describe hospital care for newborns in the Instituto Mexicano del Seguro Social (IMSS), as well as all the recommendations given to parents to prevent sudden infant death syndrome (SIDS) at home.

MATERIAL AND METHODS

There were twenty-eight IMSS hospitals randomly selected from four geographical areas of the country, under a stratified sampling method according to the number of births per year. The method used was newborns direct observation in the neonatal care areas, and to fill out a questionnaire applied by trained observers. This questionnaire was adapted from the Maternity Advice Study that includes hospital care for newborns and all the recommendations that parents have to do for newborns at home.

RESULTS

The newborns in neonatal areas used to sleep in lateral position (80 and 67%). Baby cradles with medium firmness and elevated head-rest were predominant in the areas surveyed. Babies were generally wrapped-up from the neck to down, tightly enough that it prevented arm and leg movement. Parents received information on how to prevent SIDS at home, and up to 21% of them received no information at all.

CONCLUSIONS

There were no specific practices at all the hospitals in this survey to diminish SIDS. It is necessary to organize specific health actions to diminish the risk of SIDS at home.

Early discharge among late preterm and term newborns and risk of neonatal morbidity

Understanding how late preterm infants (34-36 completed weeks' gestation) are affected by discharge policies created for term infants (37-41 completed weeks' gestation) is essential for preventing postdischarge neonatal morbidity among late preterm infants. We analyzed linked birth certificate and hospital discharge data for Massachusetts between 1998 and 2002 to evaluate the risk of neonatal morbidity (defined as hospital readmission, observational stay, or both) between all vaginally delivered, live-born singleton late preterm and term infants. All infants were born at a Massachusetts hospital to a state resident and were discharged home early (<2-night hospital stay). We calculated crude and adjusted risk ratios using a modified Poisson regression and compared the timing and principal discharge diagnoses for those neonates who needed hospital readmission. Of the 1004 late preterm and 24,320 term infants in our study, 4.3% and 2.7% of infants, respectively, were either readmitted or had an observational stay. Late preterm infants were 1.5 times more likely to require hospital-related care and 1.8 times more likely to be readmitted than term infants. Among infants who were breastfed, late preterm infants were 1.8 times more likely than term infants to require hospital-related care and 2.2 times more likely to be readmitted. In contrast, no differences were found between late preterm and term infants who were not breastfed. Jaundice and infection accounted for the majority of readmissions. Our findings suggest that late preterm infants discharged early experience significantly more neonatal morbidity than term infants discharged early; however, this may be true only for breastfed infants. Evidence-based recommendations for appropriate discharge timing and postdischarge follow-up for these late preterm infants are needed to prevent neonatal morbidity.

Babies and bacteria: phage typing, bacteriologists, and the birth of infection control

During the 1950s, Staphylococcus aureus became a major source of hospital infections and death, particularly in neonates. This situation was further complicated by the fact that Staphylococcus quickly gained resistance to most antibiotics. Controlling these infections was a pressing concern for hospital workers, especially bacteriologists who tackled it through the use of a new epidemiologic tool: phage typing. This article argues that during the mid- to late 1950s a series of staphylococcal hospital and nursery epidemics united phage typers, brought international recognition to the usefulness of their technique, and, in the process, contributed to the establishment of the new field of infection control. Through the use of this new tool, phage typers established themselves as experts in infection control and, in some places, became essential members of newly formed infection-control committees. The nursery epidemics represent a particularly important test for phage typing and infection control, for this staphylococcal strain (80/81) was especially virulent and spread rapidly beyond the hospital to the wider community. The epidemiologic information provided by phage typers was vital for devising practical advice on how to control this deadly strain of Staphylococcus and also for transforming the role of the hospital bacteriologist from mere technician into infection-control expert.

Transforming culture: an exploration of unit culture and nursing retention within a neonatal unit

In 2001, the Neonatal Unit, at The Royal Women's Hospital in Melbourne experienced the beginning of an extended period of increased demand with bed numbers in excess of 100% occupancy on many occasions, resulting in increased stress, absence of team work and low morale. Because of these demands and human resource issues there was an inability to recruit new nursing staff and retain skilled neonatal nurses. The present study will describe the key problems and highlight the activities and results of a project designed to improve nurse retention, increase employment attraction and improve recruitment outcomes. The project has been progressively successful in achieving full staffing with no ongoing nursing vacancies, reduced attrition and absenteeism, and improved interdisciplinary team work and staff satisfaction in a relatively short period. This has been sustained over 3 years.

Back transport of neonates: effect on hospital length of stay

INTRODUCTION

In a regionalized perinatal system, recovering neonates may be back transported from a regional Neonatal Intensive Care Unit (NICU) to community hospitals closer to their residence to convalesce prior to hospital discharge.

OBJECTIVE

This study evaluates the practice of neonatal back transport for growth and the duration of total hospitalization.

METHODS

We conducted a retrospective study comparing length of stay (LOS) for infants back transported from a regional NICU to a level II nursery for convalescent care (BT), with LOS for infants eligible for back transport discharged home from the Regional Center (RC).

RESULTS

A total of 221 infants were studied. BT infants (n=104) had lower birth weights (median; 1955 vs 2700 g, p=0.001), more frequently needed mechanical ventilation (84 vs 65%, p=0.002) and parenteral nutrition (71 vs 55%, p=0.013), less frequently were evaluated by subspecialists (20 vs 59% p=0.0001), and had longer total LOS (median; 20 vs 11 days, p<0.0001) compared to infants discharged home from the RC (n=117). However, in the subgroup with birth weights <or=1500 g (very low birth weight (VLBW)), BT (n=25) infants had similar birth weight (median; 1160 vs 1215 g, p=0.9) compared to those discharged home from the RC (n=24) and did not have a statistically different total LOS (median; 50 vs 56 days, p=0.1). Almost all infants who had major surgeries, treatment for retinopathy of prematurity, seizures, or had severe intra-ventricular hemorrhages were discharged home from the RC. The rates of hospital readmissions or emergency room visits acutely after their discharge to home from the RC or the community hospital were similar.

CONCLUSIONS

BT Infants differed based on clinical features compared to premature infants discharged from the RC. VLBW infants, back transported for growth, had similar total LOS compared to similar weight infants discharged home from the RC.

Exclusive versus predominant breastfeeding in Italian maternity wards and feeding practices through the first year of life

Determinants of exclusive versus predominant breastfeeding in the maternity ward and the relationship with later feeding practices were investigated in 1656 mothers who breastfed exclusively or predominantly in the maternity ward. Mothers were interviewed through 12 months postdelivery about feeding practices. Information about the World Heath Organization's (WHO's) 10 steps was collected. At hospital stay, breastfeeding was predominant in 43% of infants. Cesarean section (odds ratio [OR] = 1.75), mother's overweight (OR = 1.74), and non-compliance with the WHO's steps 6 (OR = 1.58), 7 (OR = 1.43), and 8 (OR = 1.76) were determinants of predominant, as opposed to exclusive, breastfeeding. Mothers exclusively, rather than predominantly, breastfeeding in the hospital showed a longer duration of full breastfeeding (mean = 3.6 vs 3.1 months), later introduction of formula (3.8 vs 3.3 months), and lower rate of introduction of formula within 1 month (23% vs 30%). Hospitals need to be compliant with the WHO's steps, and Baby-Friendly Hospital Initiatives should be promoted.

Perinatal mortality in the Special Care Nursery of Moi Teaching and Referral Hospital, Eldoret, Kenya

OBJECTIVES

To determine the mortality rate and causes of death of all infants admitted to the Special Care Nursery (SCN) of a tertiary referral hospital in rural Kenya.

DESIGN

Prospective and Cross-sectional study

SETTING

Special Care Nursery, Moi Teaching and Referral Hospital, Eldoret, Kenya.

SUBJECTS

All infants admitted to the Special Care Nursing (SCN).

MAIN OUTCOME MEASURES

Survival status at seven postnatal days; major causes of mortality and morbidity.

RESULTS

Three hundred and thirty five babies were studied between February and September 1999. Out of these 167 (49.9%) were male. There were 50 (15%) preterm and 124 (37.3%) low birth weight babies. There were 198 (76.2%) appropriate for gestational age (AGA), 46 (17.7%) small for gestational age and 16 (6.2%) large for gestational age babies. The seven day mortality rate of infants admitted to the Special Care Nursery was 66 (19.7%). Birth asphyxia and respiratory distress accounted for most deaths. Infants who were admitted primarily because the mother remained under general anesthesia generally did well. Logistic factors, including inadequate training for neonatal resuscitation in ward cadre of staff, unavailability of trained paediatricians and obstetricians, and inadequate operating theatre supplies were all found to delay treatment and likely to increase mortality.

CONCLUSION

Morbidity and mortality of infants born at the MTRH remain high. The most common cause of mortality remains birth asphyxia. Some causative factors, such as lack of resources or personnel, are logistic and could be rectified. Antenatal care had a significant positive impact on both morbidity and mortality.

Levels of neonatal care

The concept of designations for hospital facilities that care for newborn infants according to the level of complexity of care provided was first proposed in 1976. Subsequent diversity in the definitions and application of levels of care has complicated facility-based evaluation of clinical outcomes, resource allocation and utilization, and service delivery. We review data supporting the need for uniform nationally applicable definitions and the clinical basis for a proposed classification based on complexity of care. Facilities that provide hospital care for newborn infants should be classified on the basis of functional capabilities, and these facilities should be organized within a regionalized system of perinatal care.

Early discharge after delivery. A study of safety and risk factors

The increased frequency of early discharge of newborns has led to questions of its safety. Most studies have looked at mortality and rehospitalization, not all missed diagnoses. The purpose of this study was to determine diagnoses in newborn infants that would have been missed if the infant had been discharged in <24 h. The design was a cohort study at Rabin Medical Center-Beilinson Campus (average monthly deliveries 1996 [250], 1997 [500]), a university-affiliated community hospital with all in-born term (> or = 37 weeks) infants born September through November 1996 and June 1997. The main outcome measures were medical diagnoses (except trivial physical descriptions) noted at discharge (generally at > or =48 h) exam, not noted on admission exam (<24 h). The results showed that 54 infants (5.1%) had diagnoses that were not detected before the infant was 24 h of age. The leading diagnosis was hyperbilirubinemia. Other potentially missed diagnoses included congenital heart disease (n = 10), morbidity of birth trauma (n = 9), metabolic disturbances (n = 2), hip dislocation (n = 1), suspected sepsis (n = 2), excessive weight loss (n = 2), polycythemia (n = 2), inguinal hernia (n = 1), and abducens paresis (n = 1). It is concluded that diagnoses can be missed by discharging infants in 24 h or less. These diagnoses have the potential for adverse sequela. Even if early discharge is felt to be cost effective, parents should be counseled that it is not risk free. Better mechanisms should be put in place for assuring the safety of such infants.

Causes of nursery death beyond the neonatal period

OBJECTIVE

To investigate causes of death in infants who died after 28 days, beyond the neonatal period but before discharge from the nursery, to establish their clinical courses and causes of death and to attempt to find criteria for earlier identification of these infants.

METHODS

We identified 30 such infants (12% of nursery deaths) from 1993 through 1998 and conducted a retrospective review of their records including placental pathology and autopsy reports when available. In all, 14 infants who weighed <or = 860 g at birth were matched with survivors.

RESULTS

The 30 infants divided almost equally into two groups. Of them 15 infants weighing >or = 880 g died of diverse congenital anomalies, including five with nonhemolytic hydrops and four with pulmonary hypoplasia. One infant without congenital anomaly weighed 3290 g. Support for this severely asphyxiated infant was withdrawn after 103 days because of progressive cortical atrophy. The remaining 14, the largest of which weighed 860 g, died of complications of prematurity, which we termed postponed neonatal deaths (PND). They followed a typical course of progressive multiple organ failure. All received assisted ventilation and postnatal steroids, developed chronic lung disease, and were on ventilation at the time of death. Renal insufficiency occurred late in the course. Acute infections and renal failure were the major proximal causes of death. When compared with surviving controls the PND were less likely to have received antenatal steroids and received more inotropic agents for cardiovascular support and more amphotericin for fungal infection; surgery for perforated bowel was confined to the PND.

CONCLUSIONS

The incidence of postneonatal nursery deaths has not changed in more than 20 years remaining at 11 to 12% of nursery deaths. Congenital anomaly was a prominent cause of death (50%). When infants without congenital anomalies (PND) were compared to surviving controls, no differences were found, which could reliably identify PND early in their course. The only potentially preventable factor was lack of antenatal steroid exposure in the PND.

Trends in infant abduction

Progress has been made in reducing the number of infant abductions in the last five years, but there are still some serious problems for security and nursing managers, not the least of which is complacency. The article analyzes statistics on infant kidnapping which have been maintained by the National Center for Missing & Exploited Children (NCMEC) since 1983.

Reasons hospitals give for not offering hepatitis B vaccine to low-risk newborns

After a temporary suspension of hepatitis B vaccination (HBV) for low-risk newborns in July 1999, some hospitals still do not offer HBV to these infants. A semi-structured telephone survey of medical directors from a national random sample of 296 hospital nurseries was completed from August 2000 to April 2001 and analyzed using qualitative techniques. Directors of 201 of 290 eligible nurseries (71%) participated. Twenty-ight nurseries have never offered HBV to low-risk newborns ("Never Offered HBV") and 37 nurseries had offered HBV to low-risk newborns before July 1999, but discontinued this practice after the temporary suspension ("Discontinued HBV"). Common reasons for not offering HBV to low-risk newborns were difficulty with reimbursement and convenience of outpatient administration. In addition, directors of "Never Offered HBV" nurseries cited low disease incidence in their patient population, whereas directors of "Discontinued HBV" cited preference for the combination hepatitis B-Haemophilus influenza type b vaccine as important factors. Multi-faceted interventions may be necessary to increase HBV use in the nursery.

Postpartum discharge preferences of pediatricians: results from a national survey

OBJECTIVE

To identify practice/physician characteristics that influence pediatricians' self-reported newborn discharge practices.

METHODS

Of the pediatricians randomly surveyed through a national American Academy of Pediatrics periodic survey conducted in 2000, 490 were identified as routinely providing care for newborns in the nursery. These respondents rated the importance of 22 infant, maternal, and peripartum factors in determining readiness for nursery discharge on a 5-point Likert scale and reported their perceptions of optimal and minimal lengths of stay (LOS) for healthy term newborns. Importance of readiness factors was dichotomized as "high" (very important or important) versus "low" (neither, unimportant, or very unimportant). Relationships between pediatricians' responses and demographic information were explored using multivariate logistic regression.

RESULTS

Most pediatricians (at least 81%) rated all 7 infant clinical factors (eg, stable, normal vital signs, successful feeding) as highly important determinants of discharge readiness. Women were 2 to 3 times more likely to rate maternal and peripartum factors such as maternal fatigue and stress, demonstration of maternal skills, breastfeeding knowledge or experience, adequacy of social support, maternal age <18 years, and low income/lack of financial resources as highly important. With respect to hospital LOS, women were twice as likely to identify an optimal LOS as >36 hours and a minimal LOS as >24 hours. Pediatricians in group settings were 3 times as likely as those in solo or 2-physician practices to advocate an optimal LOS >36 hours, and those with a high proportion of publicly insured or uninsured patients were less likely to identify an optimal LOS as >36 hours (odds ratio: 0.53).

CONCLUSIONS

Female pediatricians report a more biopsychosocial approach to determining discharge readiness than their male counterparts, taking into account infant characteristics, maternal skills, and socioemotional issues that may affect the mother-infant pair's adjustment at home. The finding that those who provide care for the most financially vulnerable patients do not see the need for longer LOS is both surprising and of concern. The results support the need for a prospective critical examination of perinatal hospital discharge practices, such as the Pediatric Research in Office Settings Life Around Newborn Discharge Study.

Neonatal health care costs related to smoking during pregnancy

RESEARCH OBJECTIVE

Much of the work on estimating health care costs attributable to smoking has failed to capture the effects and related costs of smoking during pregnancy. The goal of this study is to use data on smoking behavior, birth outcomes and resource utilization to estimate neonatal costs attributable to maternal smoking during pregnancy.

STUDY DESIGN

We use 1995 data from the Center for Disease Control's (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) database. The PRAMS collects representative samples of births from 13 states (Alabama, Alaska, California, Florida, Georgia, Indiana, Maine, Michigan, New York (excluding New York City), Oklahoma, South Carolina, Washington, and West Virginia), and the District of Columbia. The 1995 PRAMS sample is approximately 25 000. Multivariate analysis is used to estimate the relationship of smoking to probability of admission to an NICU and, separately, the length of stay for those admitted or not admitted to an NICU. Neonatal costs are predicted for infants 'as is' and 'as if' their mother did not smoke. The difference between these constitutes smoking attributable neonatal costs; this divided by total neonatal costs constitutes the smoking attributable fraction (SAF). We use data from the MarketScantrade mark database of the MedStattrade mark Corporation to attach average dollar amounts to NICU and non-NICU nursery nights and data from the 1997 birth certificates to extrapolate the SAFs and attributable expenses to all states.

PRINCIPAL FINDINGS

The analysis showed that maternal smoking increased the relative risk of admission to an NICU by almost 20%. For infants admitted to the NICU, maternal smoking increased length of stay while for non- NICU infants it appeared to lower it. Over all births, however, smoking increased infant length of stay by 1.1%. NICU infants cost $2496 per night while in the NICU and $1796 while in a regular nursery compared to only $748 for non-NICU infants. The combination of the increased NICU use, longer stays and higher costs result in a positive smoking attributable fraction (SAF) for neonatal costs. The SAF across all states is 2.2%. Across the states, the SAF varied from a low of 1.3% in Texas to a high of 4.6% in Indiana.

CONCLUSIONS

These results further confirm the adverse effects of smoking. Among mothers who smoke, smoking adds over $700 in neonatal costs. The smoking attributable neonatal costs in the US represent almost $367 million in 1996 dollars; these costs vary from less than a million in smaller states to over $35 million in California. These costs are highly preventable since the adverse effects of maternal smoking occur in the short-run and can be avoided by even a temporary cessation of maternal smoking. These cost estimates can be used by managed care plans, state and local public health officials and others to evaluate alternative smoking cessation programs.

Magnitude of the problem of retinopathy of prematurity. experience in a large maternity unit with a medium size level-3 nursery

This report describes the extent and severity of retinopathy of prematurity (ROP) in a large maternity unit. The screening of 79 preterm babies showed that ophthalmic examinations should become an important part of neonatal care.

Hepatitis B vaccination practices in hospital newborn nurseries before and after changes in vaccination recommendations

BACKGROUND

Routine use of hepatitis B vaccine for low-risk newborns was suspended on July 7, 1999, because of concern about the potential risk of thimerosal, a mercury-containing vaccine preservative. Reinstatement of the birth dose was recommended when a thimerosal-free vaccine became available.

OBJECTIVE

To explore changes in hepatitis B vaccination practices for newborns related to the revised recommendations for low-risk infants (in this study, the terms newborn and infant are used interchangeably).

DESIGN

A telephone survey of a random sample of 1000 US hospitals.

PARTICIPANTS

Nurse managers, nursery directors, and staff nurses of the newborn nurseries.

MAIN OUTCOME MEASURES

Nursery vaccination practices before and after July 7, 1999, and the availability and use of thimerosal-free vaccine.

RESULTS

Interviews were conducted with 773 (87%) of 886 eligible hospitals. Before July 7, 1999, 78% of the hospitals reported vaccination practices that were consistent with recommendations at that time, although only 47% vaccinated all low-risk infants at birth. After July 7, 1999, almost all hospitals discontinued vaccination of low-risk infants, in accordance with the recommendation change; however, there was a 6-fold increase in the number of hospitals that were not vaccinating all high-risk infants. After the introduction of thimerosal-free vaccine, only 39% of the hospitals reported vaccinating all low-risk infants.

CONCLUSIONS

Most hospital nurseries altered their newborn hepatitis B vaccination practices consistent with changes in national recommendations. However, unintended consequences included the failure of some hospitals to continue vaccinating all high-risk infants and the delay in reintroducing vaccination for low-risk newborns after the introduction of a thimerosal-free vaccine. Assessments of the appropriateness of this country's response to the threat of thimerosal in vaccines should consider these findings.

Late onset infection in very low birth weight infants in Malaysian Level 3 neonatal nurseries. Malaysian Very Low Birth Weight Study Group

BACKGROUND

The purpose of this study was to examine the rate and mortality from late onset infection occurring in very low birth weight infants admitted to Malaysian nurseries.

METHODS

Data on all infants 1500 g or below admitted to the 20 participating Level 3 nurseries were analyzed for late onset infection (clinical infection and positive blood or cerebrospinal fluid culture occurring after 48 h of life).

RESULTS

The overall survival of the 962 study infants was 69%. The rate of late onset infection was 19.3%. The mortality in those with late onset infection was 30.8%. The most common infecting organism was Klebsiella pneumoniae, accounting for 38.3% of infections and 46.9% of deaths in infants with infection, followed by coagulase-negative staphylocci, 17.6 and 12.2%, respectively. On logistic regression analysis risk factors for late onset gram-negative compared with gram-positive infection were endotracheal intubation at birth and blood transfusion. Hypoglycemia was associated with gram-positive infection.

CONCLUSION

The late onset infection rate in Malaysian very low birth weight infants does not differ from that reported from developed countries, but the mortality is higher. This could be because of an excess of gram-negative infections.

Understanding newborn infant readmission: findings of the Ontario Mother and Infant Survey

The Ontario Mother and Infant Survey examined health and social service utilization of postpartum women and newborn infants from five hospital sites. A cross-sectional multilanguage survey design with longitudinal follow-up was used: 1,250 eligible, consenting women completed a self-report questionnaire in hospital and 875 women participated in a structured telephone interview at four weeks post-discharge. Rates of newborn infant readmission ranged from 2.4% to 6.7%. The best predictors of readmission were: main source of household income was other than employment; maternal self-rating of health was poor; mother anticipated inadequate help and support at home following discharge; mother received help from friends/neighbours following discharge; and mother had concern about infant care and behaviour. Readmission was not associated with length of postpartum hospital stay. The study findings suggest that there is a complex relationship between infant health care needs, family resources and provider practices that produces clinically important, site-specific readmission patterns.

Impact of the Joint Statement by the American Academy of Pediatrics/US Public Health Service on thimerosal in vaccines on hospital infant hepatitis B vaccination practices

OBJECTIVE

To determine the impact of the American Academy of Pediatrics/US Public Health Service (AAP/USPHS) joint statement on thimerosal in vaccines on hospital infant hepatitis B vaccination policies in Wisconsin.

METHODS

The nurse managers of hospital newborn nurseries (n = 110) were surveyed by mail. Nonresponders were resurveyed. Twelve hospitals no longer provided obstetric services. Of the remaining 98 hospitals, 84 (86%) responded to the initial mailing and 14 (14%) responded to the second mailing. The number of hospitals that offered hepatitis B vaccine to infants before July 1999 was compared with that in March 2000. The number of hospitals that had policies in place to vaccinate infants whose mothers' hepatitis B surface antigen status (HBsAg) was positive or unknown during the thimerosal alert (July 1999 through November 1999) was compared with that in March 2000.

RESULTS

Before July 1999, 81% of the hospitals representing 84% of reported Wisconsin births routinely offered hepatitis B vaccine to all infants. By March 2000, 50% of hospitals, representing 43% of births, had resumed routine infant hepatitis B vaccination. Physician decision to use a combination Haemophilus influenzae type b hepatitis B vaccine was the most frequently given reason for not reinstituting infant hepatitis B vaccination. During the thimerosal alert, 23% of hospitals did not have policies to vaccinate infants whose mothers were HBsAg-positive and 51% did not have policies to vaccinate infants whose mothers' HBsAg status was unknown. By March 2000, 6% of hospitals still did not have policies to vaccinate infants whose mothers were HBsAg-positive and 24% did not have policies to vaccinate infants whose mothers' HBsAg status was unknown.

CONCLUSION

The AAP/USPHS joint statement on thimerosal in vaccines has resulted in a 38% decrease in the number of hospitals routinely offering infants hepatitis B vaccine. Although thimerosal-free hepatitis B vaccine is now available, some hospitals still do not have appropriate policies in place for vaccinating infants whose mothers' HBsAg status is positive or unknown. In the future, policymakers should include anticipated consequences that may result from changes in immunization policy in their recommendations.

Lapses in measures recommended for preventing hospital-acquired infection

This study was carried out in a rural tertiary care referral hospital in central India, to ascertain lapses made by people caring for neonates in measures recommended for preventing hospital-acquired infections. Unobtrusive observation of the healthcare personnel (doctors, nurses, mothers and hospital attendants) during care of the newborn was undertaken. Lapse in handwashing by healthcare personnel was observed around 41% of the time, although mothers practiced their instructions meticulously. Lapses in methods of hand drying were seen around 7-8% of the time, in those who did wash their hands. Gloves were not used around 21% of the time, when they should have been; and of those using gloves, they were unsterile in around 22% cases. At delivery babies were received unhygienically on approximately 67% of occasions observed. Lapses during cord care ranged from 14.2% to 28.6% and during resuscitation from 16.6% to 60% of occasions. An uncleaned stethoscope was used 75% of the time. The practice of putting a finger in the baby's mouth was observed on 18 occasions. Considerable lapses by all, in every measure recommended for the prevention of hospital-acquired infections were observed. It is concluded that nothing other than an individual's commitment is likely to be successful in preventing hospital-acquired infections.

The Effect of post-discharge surveillance and control strategies on the course of a Staphylococcus aureus outbreak in a newborn nursery

This study was carried out to evaluate changes in infection rates following the adoption of three measures for controlling a Staphylococcus aureus outbreak in a nursery. In late April and early May, 1995, an outbreak of pustular dermatitis and conjunctivitis caused by S. aureus was documented. Case patients were identified by both in-hospital and post-discharge surveillance. In-hospital surveillance included daily review of data gathered by the hospital's infection control committee; use of microbiology laboratory results; requesting charts for antibiotic prescriptions; nurses' notes, and ward rounds surveillance as indicators of S. aureus infection (SAi). Post-discharge surveillance was done by telephone survey around the 30th day after a baby's birth date. During the epidemic period, reinforcement of handwashing, daily bathing, and cord care with antiseptics combined with a cohort system of admissions, and nasal mupirocin ointment were introduced sequentially in an attempt to control the outbreak. The efficacy of these three strategies was measured through the decrease of SAi rates, detected by both in-hospital and post-discharge surveillance. A total of 5,639 babies were included in the study. In-hospital surveillance information was obtained from all patients and post-discharge surveillance in 3,506 (62.7%) patients. A total of 534 SAi were detected during the study, 47 in-hospital and 487 at post-discharge surveillance. A progressive decrease in the SAi rates could be observed after the institution of the control strategies, both in-hospital (7.6% to 0.5%) and after discharge (68.9%. to 11.7%). During the study period, the rates of infection detected in out-patients were consistently higher than those diagnosed in-hospital. Improving handwashing and nasal mupirocin ointment seem to be more effective than cohort admissions and bath and cord care with antiseptics. The high SAi rates detected only after discharge from the hospital indicate that data from post-discharge surveillance should be included to estimate the true rates of infections in newborns.

Neurodevelopmental outcome of very low birth weight babies admitted to a Malaysian nursery

OBJECTIVE

To examine the prevalence and pattern of neurodevelopmental handicap at 2 years of age in very low birth weight infants (VLBW) admitted in 1993 to a level 3 Malaysian nursery.

METHODS

All VLBW babies born in the hospital or referred for neonatal care during 1993 were enrolled prospectively in the study. At 2 years of age development was assessed using the Griffiths mental scales. Neurological, hearing and visual assessments were graded into five groups according to functional handicap. Control infants were randomly selected during attendance at a primary health care clinic.

RESULTS

One hundred and fifty VLBW infants were admitted and 82 (54.6%) survived to 2 years, of whom 77 (93.9%) were assessed. The mean General Quotient (GQ) on the Griffiths Scales was 94 (15.7) for the study group and 104 (8.3) for the 60 controls. For GQ, 21 (27.3%) of the study population were 1 or more SD below the mean (18 between 1 and 2 SD and 3 > 2 SD) compared with 1 (1.6%) of the controls who was 1-2 SD below the mean. Visual impairment occurred in 2 study infants and none of the controls. There was no hearing impairment in either group. Cerebral palsy occurred in 3 (1 mild and 2 moderate-severe) of the study group and none of the controls. Functionally 18 (23.3%) of the study group had mild handicap, 1 (1.3%) moderate, 2 (2.5%) severe, 2 (2.5%) multiply severe and 54 (70.2%) were normal.

CONCLUSION

Although survival was low, overall rates of functional handicap were similar to those reported in developed countries but the proportion with moderate or severe handicap was low.

Detection of cardiovascular abnormalities in the nursery of a general hospital in the Amazon region: correlation with potential risk factors

Congenital heart diseases have been studied much more extensively in children than in neonates. In this study, we report on the findings from 57 neonates seen from June of 1995 through June 1996 in the nursery of a large public hospital in Belém, Pará, Brazil. All were routinely examined by a paediatrician just after birth, and, when indicated, these babies were referred to the cardiology unit of our Hospital for assessment by a paediatric cardiologist. Most of the diagnoses were made by means of Doppler and cross-sectional echocardiography with color flow mapping. Several abnormalities of the cardiovascular system were diagnosed. The most frequent was patency of the arterial duct. But, since many ducts closed spontaneously, ventricular septal defect was the most frequent lesion seen even in the nursery. Four defects (patent arterial duct, ventricular septal defect, atrial septal defect and pulmonary stenosis) together accounted for two thirds of all cardiac abnormalities. Associated non-cardiac anomalies were more frequent in those with simple lesions within the heart. All the babies with complex heart disease, and the majority of those designated as having significant lesions, died before they could be discharged. Several risk factors were investigated. Among maternal drugs, misoprostol emerged as having a possible teratogenic effect.

Nursery practices and detection of jaundice after newborn discharge

OBJECTIVE

To investigate nursery practices regarding outpatient recognition of neonatal jaundice.

DESIGN

Descriptive survey.

PARTICIPANTS

Random sample of nursery head nurses and pediatricians from national lists.

SETTING

Nurseries with more than 100 births per year and pediatricians responsible for newborn discharges.

RESULTS

Head nurses from 204 nurseries and 200 pediatricians were surveyed, with 62% of head nurses and 55% of pediatricians responding. Almost half of the head nurses (45%) reported lack of a written neonatal jaundice protocol. Twenty-seven percent of head nurses and pediatricians reported that no system is in place to track jaundiced newborns after discharge. Forty percent of head nurses and 26% of pediatricians reported from higher-risk nurseries, defined as nurseries where more than 25% of mothers did not have a high school diploma or more than 50% of infants were born to single-parent families. These nurseries were no more likely to have a protocol for jaundice management or to use a system to track newborns after discharge. Discharge of most newborns before 36 hours of age was common (70% of head nurses, 62% of pediatricians) and some respondents discharged most newborns before 24 hours of age (16% of head nurses, 12% of pediatricians). For newborns discharged before 24 hours of age, more than half of the nurseries surveyed scheduled follow-up within 2 to 3 days (53% of head nurses, 62% of pediatricians). The likelihood of such follow-up did not differ by type of health care insurance, level of maternal education, percentage of single-parent families, predominance of minority patients, or higher risk as defined above.

CONCLUSIONS

In our sample, many nurseries lack parent education, neonatal jaundice protocols, and neonatal jaundice tracking systems. Newborns discharged before 48 hours of age are often not scheduled to be seen by a health care provider within 2 to 3 days, despite American Academy of Pediatrics guidelines recommending such follow-up.

Clinical sepsis and death in a newborn nursery associated with contaminated parenteral medications--Brazil, 1996

In October 1996, a total of 35 newborn infants died in a 26-bed nursery of a 200-bed hospital in Roraima, Brazil; these deaths represented a significant increase over the baseline mortality rate in the nursery (6.0 versus 1.7 per 100 live births; p<0.01). Twenty of the deaths were attributed to sepsis. Fatal episodes of sepsis began 24-72 hours after birth. Although an investigation by the Roraima Health Department resulted in an improvement of infection control, increased episodes of fever and clinical sepsis persisted. As a result, in November 1996, the Secretary of Health of Roraima, Brazil Ministry of Health, requested that CDC assist in the investigation. This report summarizes this investigation, which implicated locally produced intravenous (IV) solutions as the source of the outbreak and underscores the need to assure proper quality control of parenteral medications and the importance of nosocomial infection surveillance.

Survey of newborn security in British Columbia hospitals. Review Committee on Newborn Security. Provincial Ministry of Health

The abduction of a newborn from Kelowna General Hospital, Kelowna, BC, in September 1996 resulted in the formation of a newborn security review team by the province's Ministry of Health and the British Columbia Health Association. Part of the duties of the review team was the surveying of 87 hospitals in British Columbia that provide maternity services on current security protocols in each facility. Results of the survey are presented in this article, along with the subsequent recommendations of the review committee.

Hospital readmission with feeding-related problems after early postpartum discharge of normal newborns

CONTEXT

Increasingly short postpartum hospital stays in the United States precipitated a policy debate that culminated in passage of the Newborns' and Mothers' Health Protection Act of 1996. The debate occurred without population-based evidence for adverse health effects in newborns who are discharged early.

OBJECTIVE

To determine whether early postpartum hospital discharge of normal newborns increases their risk for hospital readmission with feeding-related problems.

DESIGN AND SETTING

Nested case-control analysis of 1991 to 1994 Wisconsin birth certificate and hospital discharge data.

SUBJECTS

A total of 210 readmitted case patients and 630 control subjects selected from a cohort of 120 290 normal newborns who weighed at least 2500 g, were delivered vaginally of mothers with uncomplicated medical and obstetrical histories, and were discharged from the hospital either early (day of life 1 or 2) or conventionally (day 3).

OUTCOME MEASURE

Readmission at age 4 to 28 days with discharge diagnoses indicating a primary feeding problem, secondary dehydration, or inadequate weight gain.

RESULTS

Early discharges increased 3-fold (reaching 521/1000 discharges) during the study period, but feeding-related readmissions (1.7/1000) remained stable. Most readmitted newborns (53.8%) were 4 to 7 days old, many (34.3%) had concurrent dehydration and jaundice, and 29% were admitted through emergency departments. Readmitted newborns were significantly (P<.05) more likely to have been breast-fed, firstborn, or preterm or to have mothers who were poorly educated (<12th grade), unmarried, or receiving Medicaid. Readmission was not associated with early discharge (adjusted odds ratio, 1.05; 95% confidence interval, 0.71-1.53).

CONCLUSION

Although several neonatal and maternal factors increase the risk that a normal newborn will be rehospitalized with a feeding-related problem, early discharge following an uncomplicated postpartum hospital stay appears to have little or no independent effect on this risk.

The safety of newborn early discharge. The Washington State experience

CONTEXT

While early discharge of newborns following routine vaginal delivery has become common practice, its safety has not been firmly established.

OBJECTIVE

To assess the risk for rehospitalization following newborn early discharge.

DESIGN

Population-based, case-control study.

SETTING

Washington State linked birth certificate and hospital discharge abstracts covering 310578 live births from 1991 through 1994.

PATIENTS

Case patients were 2029 newborns rehospitalized in the first month of life. Control subjects were 8657 randomly selected newborns not rehospitalized and frequency matched to case patients on year of birth. Cesarean deliveries, multiple births, and births at less than 36 weeks' gestation were not included.

MAIN OUTCOME MEASURE

Stratified analyses and logistic regression were performed to assess the risk for rehospitalization within a month of birth after early discharge (<30 hours after birth) compared with later discharge (30-78 hours after birth).

RESULTS

Seventeen percent of newborns were discharged early. Newborns discharged early were more likely to be rehospitalized within 7 days (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.11-1.47), 14 days (OR, 1.16; 95% CI, 1.03-1.32), and 28 days (OR, 1.12; 95% CI, 1.00-1.25) of discharge than newborns sent home later. Subgroups at increased risk for rehospitalization following early discharge included newborns born to primigravidas (OR,1.25; 95% CI, 1.07-1.45), mothers younger than 18 years (OR, 1.22; 95% CI, 0.79-1.91), and mothers with premature rupture of membranes (OR, 1.41; 95% CI, 0.85-2.36). Early discharge was also associated with an increased risk of readmission for jaundice, dehydration, and sepsis.

CONCLUSION

Newborns discharged home early (<30 hours after birth) are at increased risk for rehospitalization during the first month of life.

[Colonization with group B streptococci in neonates and premature infants from selected neonatal departments]

Group B streptococci are considered an important etiological agent of sepsis and meningitis in neonates and, particularly, in premature infants. There is a close correlation between colonization with these bacteria and the frequency of symptomatic infection. It is estimated that symptomatic infections occur in 1.0% of colonised neonates. The purpose of this work was to investigate the frequency of neonate colonization with group B streptococci for determination of the risk of symptomatic infection.

The impact of prenatal exposure to cocaine on newborn costs and length of stay

OBJECTIVE

Our intention is to determine newborn costs and lengths of stay attributable to prenatal exposure to cocaine and other illicit drugs.

DATA SOURCES AND STUDY SETTING

All parturients who delivered at a large municipal hospital in New York City between November 18, 1991 and April 11, 1992.

STUDY DESIGN

A cross-sectional analysis used multivariate, loglinear regressions to analyze differences in costs and length of stay between infants exposed and unexposed prenatally to cocaine and other illicit drugs, adjusting for maternal race, age, prenatal care, tobacco, parity, type of delivery, birth weight, prematurity, and newborn infection.

DATA COLLECTION/EXTRACTION METHODS

Urine specimens, with linked obstetric sheets and discharge abstracts, provided information on exposure, prenatal behaviors, costs, length of stay, and discharge disposition.

PRINCIPAL FINDINGS

Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed. Approximately 60 percent of these costs are indirect, the result of adverse birth outcomes and newborn infection. Hospital screening as recorded on discharge abstracts substantially underestimates prevalence at delivery, but overestimates its impact on costs.

Hospital breast-feeding practices in Ontario

The breast-feeding practices of Ontario hospitals with live birth rates between 1,500 and 4,000 per year were assessed in 1989 by surveying hospital dietitians. The involvement of the dietitian and/or nurse in hospital based breast-feeding education was determined and differences in hospital practices where dietitians were or were not directly involved in breast-feeding education were assessed. Completed surveys were received from 42 dietitians (84% response rate) of whom 45.5% were directly involved in teaching breast-feeding classes. Practices that could be considered barriers to successful breast-feeding were found in 25% to 60% of the hospitals. The only significant difference between dietitian and nursing directed instruction was that plain water was less likely to be routinely offered to infants when dietitians were involved (p < 0.05). Dietitians will need to become more proactive within the hospital setting by working with health care team members in obstetrics to remove barriers to successful breast-feeding.

Infant feeding policies in maternity wards and their effect on breast-feeding success: an analytical overview

OBJECTIVES

The purpose of this review is to examine the plausibility of a causal relationship between maternity ward practices and lactation success.

METHODS

Studies were located with MEDLINE, from our personal files, and by contacting researchers working in this field. Of the 65 studies originally reviewed, 18 met our inclusion criteria (i.e., hospital-based intervention, experimental design with randomization procedures, or quasi-experimental design with adequate documentation).

RESULTS

Meta-analysis indicated that commercial discharge packs had an adverse effect on lactation performance. The impact of early mother-infant contact on lactation success was unclear. Rooming-in and breast-feeding guidance in a rooming-in context had a beneficial impact on breast-feeding among primiparae. Breast-feeding on demand was positively associated with lactation success. In-hospital formula supplementation of 48 mL per day was not associated with poor breast-feeding performance.

CONCLUSIONS

Hospital-based breast-feeding interventions can have a beneficial effect on lactation success, particularly among primiparous women.

Light variability in the modern neonatal nursery: chronobiologic issues

The role that nursery light variability may play in modulating infant biological rhythms is being studied in Stanford Medical Center's Neonatal Intensive Care (NICU) and Intermediate Care (IN) Nurseries. In this investigation, spatial and temporal variability in illuminance was determined at 20 sites within each nursery over a 5-day period. The analysis of 240 measurements at 30 min intervals from each site revealed marked variability in illumination with respect to both time and position in the nursery. These aperiodic lighting patterns differed greatly from the published characterization of NICUs as having 'constant' illumination. Light pulses of variable frequency, intensity, and duration were common at each of the 40 bedsites studied. Given the powerful impact of light on circadian rhythmicity and sleep in adults, the results from this study suggest that modern NICU lighting, while implemented to facilitate intensive care, may have adverse effects on infant development. Future studies on the influence of light on biological rhythmicity and sleep are essential to provide a framework for clinical and environmental interventions, which may play a significant role in improving developmental outcome in hospitalized preterm or term infants.